Food Insecurity Was Associated With Greater Family Health Care Expenditures In The US, 2016-17

Quality Improvement to Identify and Address Food Insecurity During Pediatric Hospitalizations

OBJECTIVES

Hospitalized children represent a vulnerable population with high rates of unidentified food insecurity (FI). We aimed to improve FI screening for eligible families from 0% to 60%. Secondarily, we sought to provide location-based food resources to families that screened positive.

METHODS

In February 2021, we developed a multidisciplinary team and used the Model for Improvement to improve routine FI screening for eligible children on 1 inpatient unit at a single institution. Our primary measure was the overall percentage of eligible families screened for FI. Our secondary measure was the percentage of families with FI who received food resource information. Statistical process control charts were used to analyze the impact of our interventions.

RESULTS

A total of 8850 families were eligible for screening during the project period. The percentage of eligible families screened for FI increased from 0 to a mean of 77%, exceeding our goal, with special cause variation noted by 5 centerline shifts. The most impactful interventions were expansion of screening to patients admitted to all services and making FI screening questions required nursing admission documentation. Eleven percent of families screened positive for FI. Provision of resources increased from 56% with manual resource insertion into the after-visit summary to 100% with special cause variation associated with automated resource provision for positive screens.

CONCLUSIONS

Integrating FI screening into the nursing admission workflow with automated resource provision for positive screens is a feasible approach to integrating FI screening into routine clinical practice during pediatric hospitalizations.

Patient-Provider Communication and Access, Use, and Financial Burden of Care

INTRODUCTION

Effective patient-provider communication is a critical component of optimal patient care, but its potential impact on the delivery of healthcare services remains unclear. This study examines the association of patient-provider communication with access to care, healthcare utilization, and financial burden of care.

METHODS

Using the 2013-2021 Medical Expenditure Panel Survey longitudinal data, the level of patient-provider communication was measured across four domains (attentive listening, clear explanation, respectfulness, and time allocation) as a primary independent variable, categorized into low, moderate, and high. A lagged dependent model was employed to examine the associations of patient-provider communication at baseline with subsequent access to care, healthcare utilization, and financial burden of care, controlling for baseline sample characteristics and outcomes measured at the baseline. Analysis was conducted in February 2024.

RESULTS

Among 28,955 analytic samples (representing 709,547,678 U.S. adults), 5.3%, 50.2%, and 44.3% reported low, moderate, and high levels of patient-provider communication. Marginalized populations, including racial/ethnic minorities, those with low education and income, and those lacking insurance, were more likely to report low patient-provider communication. Compared with adults with high patient-provider communication, those with low patient-provider communication were more likely to encounter difficulties in accessing medical care (2.6 percentage points; 95% CI: 1.2-3.9), experience delays in obtaining necessary medical care (2.8 percentage points; 1.3-4.4), have emergency room visits (4.2 percentage points; 1.9-6.4), and face difficulties paying medical bills (4.0 percentage points; 2.2-5.8) in the subsequent year.

CONCLUSIONS

Encouraging effective patient-provider communication is essential for advancing patient-centered care and mitigating health inequities.

Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With and Without Food Insecurity

BACKGROUND

Compared to traditional Medicare (TM), Medicare Advantage (MA) plans impose out-of-pocket cost limits and offer extra benefits, potentially providing financial relief for MA enrollees, especially for those with food insecurity.

OBJECTIVE

To examine whether the prevalence of food insecurity differs between TM and MA enrollees at baseline and then examine whether MA enrollment in a baseline year is associated with less financial hardships in the following year, relative to TM enrollment, especially for those experiencing food insecurity.

DESIGN

We conducted a retrospective longitudinal cohort study.

PARTICIPANTS

Our analysis included 2807 Medicare beneficiaries (weighted sample size, 23,963,947) who maintained continuous enrollment in either TM or MA in both 2020 and 2021 from the Medical Expenditure Panel Survey.

MAIN MEASURES

We assessed outcomes related to financial hardships in health care and non-health care domains (measured in 2021). Our primary independent variables were food insecurity and MA enrollment (measured in 2020).

RESULTS

The point estimate of food insecurity prevalence was greater among MA enrollees than TM enrollees, but the difference was not statistically significant (1.1 percentage points [95% CI, - 1.0, 3.4]). Furthermore, there is evidence that compared to TM enrollment, MA enrollment did not mitigate the risk of financial hardship, particularly for food-insecure enrollees. Rather, food-secure MA enrollees faced greater financial hardship in the following year than food-secure TM enrollees (11.2% [8.9-13.6] and 7.6% [6.9-8.3] for problems paying medical bills and 5.5% [4.6-6.4] and 2.8% [2.1-3.6] for paying medical bills over time). Moreover, the point estimate of financial hardship was higher among food-insecure MA enrollees than food-insecure TM enrollees (21.5% [5.4-37.5] and 11.2% [4.1-18.4] and 23.7% [9.6-37.9] and 6.9% [0.5-13.3]) despite the lack of statistical significance.

CONCLUSION

These findings suggest that the promise of financial protection offered by MA plans has not been fully realized, particularly for those with food insecurity.

Social Isolation, Loneliness, and Quality of Life Among Food-Insecure Adults

INTRODUCTION

Food insecurity is associated with adverse health outcomes, but may also have a detrimental effect on social relationships, potentially exacerbating social isolation and loneliness, and consequently affecting health-related quality of life. This study examined the associations of food insecurity with social isolation, loneliness, and health-related quality of life among U.S. adults.

METHODS

A retrospective cohort study was conducted using panel data from the 2020-2021 Medical Expenditure Panel Survey. Regression models were used to assess the associations of food insecurity in 1 year with the outcomes of interest in the subsequent year while adjusting for baseline individual-level characteristics. Analysis was conducted in December 2023.

RESULTS

Experiencing food insecurity in 2020 was significantly associated with increased reports of social isolation (3.1 percentage points [95% CI: 1.2-5.1]) and loneliness (9.7 percentage points [95% CI: 1.0-18.3]) in 2021. Additionally, food insecurity in 2020 was significantly associated with lower self-reported good mental health (-2.9 percentage points [95% CI: -5.1, -0.6]) and mental component summary score from the Short Form-12 Health Survey (-3.3 points [95% CI -3.8, -2.9]) in 2021. However, there were no or small associations with physical health-related quality of life.

CONCLUSIONS

Food insecurity is associated with worse social and mental well-being among U.S. adults. This suggests that food insecurity interventions should not focus too narrowly on nutrition, but instead give holistic consideration to the multiple ways food insecurity harms health-not only via lower quality diets, but through worse mental health and impairing the ability to participate in social life.

Multisector Collaboration vs. Social Democracy for Addressing Social Determinants of Health

Policy Points Multisector collaboration, the dominant approach for responding to health harms created by adverse social conditions, involves collaboration among health care insurers, health care systems, and social services organizations. Social democracy, an underused alternative, seeks to use government policy to shape the civil (e.g., civil rights), political (e.g., voting rights), and economic (e.g., labor market institutions, property rights, and the tax-and-transfer system) institutions that produce health. Multisector collaboration may not achieve its goals, both because the collaborations are difficult to accomplish and because it does not seek to transform social conditions, only to mitigate their harms. Social democracy requires political contestation but has greater potential to improve population health and health equity.

Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review

Household food insecurity has significant negative implications across the lifespan. While routine screening is recommended, particularly in healthcare, guidelines are lacking on selection of screening tools and best-practice implementation across different contexts in non-stigmatizing ways. The objective of this scoping review was to synthesize evidence on household food insecurity screening tools, including psychometrics, implementation in a range of settings, and experiences of carrying out screening or being screened. Four electronic databases were searched for studies in English published from 1990 until June 2023. A total of 58 papers were included, 21 of which focused on tool development and validation, and 37 papers described implementation and perceptions of screening. Most papers were from the USA and described screening in healthcare settings. There was a lack of evidence regarding screening in settings utilized by Indigenous people. The two-item Hunger Vital Sign emerged as the most used and most valid tool across settings. While there is minimal discomfort associated with screening, screening rates in practice are still low. Barriers and facilitators of screening were identified at the setting, system, provider, and recipient level and were mapped onto the COM-B model of behavior change. This review identifies practical strategies to optimize screening and disclosure.

Association of food insecurity with health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic

OBJECTIVES

To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets.

STUDY DESIGN

We conducted a retrospective longitudinal cohort study using the 2020-2021 Medical Expenditure Panel Survey.

METHODS

Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage.

RESULTS

Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage.

CONCLUSIONS

Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences.

Caregiver Preferences for Primary Care Clinic-Based Food Assistance: A Discrete Choice Experiment

OBJECTIVE

The American Academy of Pediatrics recommends that pediatric providers screen families for food insecurity and connect them to appropriate resources. However, it is unclear how clinics can best provide families with resources consistent with their needs and preferences. In this study, we elicited caregiver preferences for clinic-based food assistance.

METHODS

We conducted a cross-sectional discrete choice experiment in which caregivers at 2 pediatric primary care clinics were asked to choose between hypothetical food programs. Programs varied across 4 categories: 1) resources provided (eg, food delivery, food in clinic, assistance enrolling in benefits); 2) support staff providing resources (eg, social worker, community health worker, physician, or nurse); 3) outreach modality (eg, phone, email, text); and 4) outreach frequency. Multinomial logistic regression was used to assess caregiver preferences within each category and the relative importance of each category to caregiver decisions.

RESULTS

We surveyed 142 caregivers who were predominantly Black (87%) and Medicaid-insured (90%). Caregiver preferences for food programs were most strongly influenced by the food resources provided. Caregivers preferred food delivery over other forms of food supports, such as food provided in clinic. They preferred assistance from a benefits enrollment specialist, community health worker, or social worker to assistance from a physician or nurse.

CONCLUSIONS

Pediatric clinics serving families at risk of food insecurity should use caregiver preferences to inform the design of family-centered interventions. Clinics should consider connecting caregivers with food delivery programs, and pediatric payors should adopt reimbursement models that support multidisciplinary team-based care to address food insecurity.

Food Insecurity and Social Policy: A Comparative Analysis of Welfare State Regimes in 19 Countries

We sought to determine whether a country's social policy configuration-its welfare state regime-is associated with food insecurity risk. We conducted a cross-sectional study of 2017 U.N. Food and Agriculture Organization individual-level food insecurity survey data from 19 countries (the most recent data available prior to COVID-19). Countries were categorized into three welfare state regimes: liberal (e.g., the United States), corporatist (e.g., Germany), or social democratic (e.g., Norway). Food insecurity probability, calibrated to an international reference standard, was calculated using a Rasch model. We used linear regression to compare food insecurity probability across regime types, adjusting for per-capita gross domestic product, age, gender, education, and household composition. There were 19,008 participants. The mean food insecurity probability was 0.067 (SD: 0.217). In adjusted analyses and compared with liberal regimes, food insecurity probability was lower in corporatist (risk difference: -0.039, 95% CI -0.066 to -0.011, p  =  .006) and social democratic regimes (risk difference: -0.037, 95% CI -0.062 to -0.012, p  =  .004). Social policy configuration is strongly associated with food insecurity risk. Social policy changes may help lower food insecurity risk in countries with high risk.

Pediatric produce prescription initiatives in the U.S.: a scoping review

BACKGROUND

To describe pediatric Produce Prescription (PRx) interventions and their study designs, outcomes, and opportunities for future research.

METHODS

A scoping review framework was used to describe PRx interventions published between January 2000 and September 2023. Articles from online databases were uploaded into Covidence. Data on study characteristics, outcomes of interest (health, food insecurity (FI), nutritional and culinary efficacy, and fruit and vegetable (F/V) consumption), and feasibility were extracted. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment.

RESULTS

19 articles met inclusion criteria. Ten studies were quantitative, five were qualitative, and four used mixed-methods. Interventions included food vouchers (n = 14) or food box/pantries (n = 5). Four studies allowed food items in addition to F/Vs. Six studies measured changes in FI and five reported a statistically significant decrease. Seven studies measured changes in F/V consumption and five reported a statistically significant increase. One study reported a statistically significant reduction in child BMI z-score. Most studies reported high feasibility. Few studies used high-quality methods.

CONCLUSIONS

Pediatric PRx interventions show promising potential to reduce FI and improve diet quality and health-related outcomes. Future studies should utilize rigorous study designs and validated assessment tools to understand the impact of pediatric PRx on health.

IMPACT

This work offers a summary of programmatic outcomes including retention, redemption, incentives, nutrition education, study design and quality limitations to help inform future work. We found positive impacts of pediatric produce prescriptions (PRx) on FI, F/V consumption, and nutritional knowledge and culinary skills. More high-quality, rigorous studies are needed to understand the best delivery and design of PRx and their impact on child behavior and health outcomes. This work provides support for the need for rigorous studies and the potential for PRx to play a role in multi-pronged strategies that address pediatric FI and diet-related disease.

Association of Supplemental Nutrition Assistance Program participation duration with cost-related medication non-adherence and emergency department visits

OBJECTIVE

Administrative requirements could disrupt sustained Supplemental Nutrition Assistance Program (SNAP) participation among income-eligible individuals. To meet their food needs, low-income individuals without consistent SNAP benefits may compromise on medication use, posing a risk to their health. The objective of this study is to examine the association of SNAP participation duration in a given year with cost-related medication nonadherence (CRN) and emergency department (ED) use in income-eligible individuals.

DESIGN

Cross-sectional.

SAMPLE

Non-elderly and elderly adults who used prescription medications and participated in SNAP the previous year in 2016-2018 National Health Interview Survey. Subsamples included individuals with specific chronic conditions.

MEASUREMENTS

CRN and ED usage.

RESULTS

SNAP participation for <12 months in the previous year was related to increased CRN and ED use in nonelderly adults taking prescription medication, as well as in those with hypertension, cardiovascular disease and asthma. Further, <12-month SNAP participation was associated with greater odds of having at least one ED visit in nonelderly and elderly adults.

CONCLUSIONS

Sustained SNAP participation could help income-eligible individuals better adhere to their prescribed medications and reduce health complications requiring ED visits. Findings suggest the importance of addressing SNAP participation gaps among income-eligible individuals in health care settings.

Feasibility of Using Text Messaging to Identify and Assist Patients With Hypertension With Health-Related Social Needs: Cross-Sectional Study

BACKGROUND

Health-related social needs are associated with poor health outcomes, increased acute health care use, and impaired chronic disease management. Given these negative outcomes, an increasing number of national health care organizations have recommended that the health system screen and address unmet health-related social needs as a routine part of clinical care, but there are limited data on how to implement social needs screening in clinical settings to improve the management of chronic diseases such as hypertension. SMS text messaging could be an effective and efficient approach to screen patients; however, there are limited data on the feasibility of using it.

OBJECTIVE

We conducted a cross-sectional study of patients with hypertension to determine the feasibility of using SMS text messaging to screen patients for unmet health-related social needs.

METHODS

We randomly selected 200 patients (≥18 years) from 1 academic health system. Patients were included if they were seen at one of 17 primary care clinics that were part of the academic health system and located in Forsyth County, North Carolina. We limited the sample to patients seen in one of these clinics to provide tailored information about local community-based resources. To ensure that the participants were still patients within the clinic, we only included those who had a visit in the previous 3 months. The SMS text message included a link to 6 questions regarding food, housing, and transportation. Patients who screened positive and were interested received a subsequent message with information about local resources. We assessed the proportion of patients who completed the questions. We also evaluated for the differences in the demographics between patients who completed the questions and those who did not using bivariate analyses.

RESULTS

Of the 200 patients, the majority were female (n=109, 54.5%), non-Hispanic White (n=114, 57.0%), and received commercial insurance (n=105, 52.5%). There were no significant differences in demographics between the 4446 patients who were eligible and the 200 randomly selected patients. Of the 200 patients included, the SMS text message was unable to be delivered to 9 (4.5%) patients and 17 (8.5%) completed the social needs questionnaire. We did not observe a significant difference in the demographic characteristics of patients who did versus did not complete the questionnaire. Of the 17, a total of 5 (29.4%) reported at least 1 unmet need, but only 2 chose to receive resource information.

CONCLUSIONS

We found that only 8.5% (n=17) of patients completed a SMS text message-based health-related social needs questionnaire. SMS text messaging may not be feasible as a single modality to screen patients in this population. Future research should evaluate if SMS text message-based social needs screening is feasible in other populations or effective when paired with other screening modalities.

Narrative review: food as medicine across the pediatric age continuum

PURPOSE OF REVIEW

Poor diet and food insecurity contribute to the dramatic rise in diet-related chronic disease and increasing cost of healthcare. The Food as Medicine (FAM) framework describes food-based interventions designed to prevent, manage, and treat diet-related diseases. However, FAM interventions have not been widely implemented or evaluated in pediatric populations, so critical questions remain about their optimal delivery and design, efficacy, and funding opportunities. We have reviewed the recent literature and offer insights into potential funding and implementation strategies for pediatric healthcare providers.

RECENT FINDINGS

Data from adult and population-level interventions provide evidence that FAM interventions positively impact diet quality, food security, health outcomes, and healthcare utilization and cost in adults and households with children. Evidence from recent pediatric-based FAM interventions and population data from recent changes to federal nutrition programs support the use of food-based interventions to improve child diet quality, food insecurity, and potentially impact long-term health and healthcare utilization and cost.

SUMMARY

Applying the entire spectrum of evidence-based FAM interventions in pediatric settings from prenatal to adolescent stages will offer the greatest opportunity to ensure all children have access to enough healthful food so they can achieve their highest potential in life.

Adverse Consequences of Food Insecurity Among U.S. Adults Beyond Health Outcomes

INTRODUCTION

Food insecurity is associated with poorer health, but the adverse consequences of food insecurity may extend beyond just health outcomes. Thus, this study examined the association between food insecurity and health insurance coverage, access to care, healthcare utilization, and financial hardships among U.S. adults.

METHODS

This study employed a retrospective longitudinal cohort study design using panel data from the 2016-2017 Medical Expenditure Panel Survey. Linear probability models were used to examine the association between food insecurity in 1 year and outcomes of interest (health insurance coverage, access to care, healthcare utilization, and financial hardships) in the subsequent year. Analysis was conducted in April 2023.

RESULTS

Food insecurity was associated with higher uninsured rates and lower private coverage rates (3.5 [95% CI: 1.6-5.5] and -3.9 [95% CI: -6.2, -1.7] percentage points). Moreover, food insecurity was associated with lower access to care, including delay in receiving necessary medical care and delay in obtaining necessary prescription drugs (2.9 [95% CI: 1.0-4.8] and 4.1 [95% CI: 2.1-6.2]). Furthermore, food insecurity was associated with a higher rate of emergency room visits (2.8 [95% CI: 0.1-5.7]), whereas associations with inpatient, outpatient, and prescription drug use were not significant. Food insecurity was also associated with greater financial hardships, such as experiencing difficulties paying medical bills (9.6 [95% CI: 6.7-12.6]).

CONCLUSIONS

These findings highlight the adverse consequences of food insecurity on access to and affordability of care for U.S. adults and families. Food insecurity can have far-reaching implications for the well-being of individuals and families.

Healthcare-based food assistance programmes in the United States: a scoping review and typology

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

Food and Nutrition Security Among Households With Children in North Carolina: Challenges, Opportunities, and Potential Policy Solutions

In North Carolina, childhood food and nutrition insecurity are persistent problems. This article explores challenges, highlights potential opportunities, and proposes policy solutions for food and nutrition insecurity among households with children. North Carolina is poised to ensure adequate, healthy, affordable, and accessible nutrition for its youngest residents.